Name:

Address:

Member No: (add $25 if not a member)

Please rush me the following;

BWA Polo Shirt. size ____ Quantity___ cost @$25ea $ ___

BWA Jumper. size ____ Quantity___ cost @$25ea $ ___

BWA flag. size 42 x 31cm Quantity___ cost @$25ea $ ___

BWA flag. size 52 x 37cm Quantity___ cost @$40ea $ ___

BWA Cap. one size Quantity___ cost @$12ea $ ___

Postage. Shirts, jumpers max cost @ $5 $ _____

Total cost $ _____

I enclose my cheque/money order made payable to Boating Western Australia.

Or please debit my: o o o

Card Number:

Expiry Date:

Signature; _________________________________

Date; _______/_______

Please print and send to:

Boating Western Australia,

PO Box 1080,

Claremont, 6910,

Western Australia.

Or Fax to 08 93353296